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Causes of Gastro-oesophageal Reflux Disease
- Hiatus Hernia
- LOS dysfunction
- Foods - fat, chocolate, caffeine
- Smoking
- Obesity
- Alcohol
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Symptoms of GORD
- Heartburn - retrosternal chest pain, particularly after meals
- Regurgitation
- Waterbrash
- Choking at night
- Dysphagia - secondary to strictures
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Investigations for GORD - When?
- Diagnosis is clinical in all patients <45, in the absence of RED FLAGS:Weight loss
- Iron deficiency anaemia
- GI bleeding
- Persistent vomiting
- Dysphagia
- Empigastric Mass
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Investigations for GORD - How?
Barium Swallow
24hr luminal pH and manometry - pH below 4 for 6-7% of the period = GORD
Endoscopy - can assess levels of inflammation and allow biopsies to be taken.
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Complications of GORD
- Barrett's oesophagus - squamous metaplasia, predisposing to oesophageal cancer
- Anaemia - Rule out colorectal Ca.
- Benign Stricture
- Gastric Volvulus
- Webs
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Treatment of GORD- Behavioural
- Raising the head when lying flat
- Weight loss
- Smoking and alcohol reduction
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Treatment for GORD - Medical
- Antacids - Magnesium tricilitate or Aluminium hydroxide
- Alginate containing antacids
- PPIs - e.g. omeprazole
- Prokinetic Agents - increase the rate of gastric emptying e.g. metocloperamide
- H. Pylori erradication
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Surgical Treatment of GORD
- Only indicated in medically unresponsive disease
- Most common type of surgery is Nissen Fundoplication
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LNF Complications
- Dysphagia
- Dumping
- Excessive scarring
- Bloating
- Achalasia
- Reversal
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Pharyngeal / Oesophageal causes of Dysphagia
- Motor Neurone Disease
- Myasthenia Gravis
- Upper Oesophageal Achalasia
- Infection - Botulism / Polio
- CVA - Damage to CN IX, X and XII *
*Most common cause
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Oesophageal causes of Dysphagia
- Achalasia
- Oesophageal spasm
- Luminal obstruction - stricture, bolus or carcinoma
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External Causes of Dysphagia
- Retrosternal Goitre
- Lung Cancer
- Pharyngeal Diverticulum
- Vascular Anomalies e.g. AAA and cardiomegaly
- Mediastinal mass
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Factors in dysphagia that point towards a diagnosis:
- Progressive Dysphagia
- Difficulty with solids > liquids
- Retrosternal pain and regurgitation
- Weight Loss
- Progressive Dysphagia = Malignancy
- Difficulty with solids > liquids = Muscular inco-ordination
- Retrosternal pain and regurgitation = suggests stricture / carcinoma
- Weight Loss = Malignancy
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Investigations for Dysphagia
- Barium Swallow - often negative and therefore rarely used
- Oesophageal Endoscopy - First line, allows visualistation, biopsy and diagnosis of cancer.
- CT scan - used to stage malignancy
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Treatment of Diseases that cause Dysphagia:
- Pharyngeal Pouches
- Achalasia
- Oesophageal Spasm
Pharyngeal Pouches -
Occurs in the elderly. Treat with endoscopic stapled pharyngoplasty.
Achalasia -
Barium swallow shows "rat's tail / bird beak" sign. Treatment can include: - - Balloon Dilation
- - Botox injection
- - Surgical Myotomy
Oesophageal Spasm -
Characterised by odynophagia (esp. with extreme temps). Treatments: - - Calcium channel blockers
- - Smooth muscle relaxants
- - Surgical myotomy rarely done.
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Pathological Types of Oesophageal Cancer
- - Squamous Carcinoma - Upper 1/2
- - Adenocarcinoma - Lower 1/2
2:1, adeno:squamous
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Risk Factors for Squamous Carcinoma of the Oesophagus:
- Smoking
- Alcohol
- Increased nitrosamines intake
- Vitamin A deficiency
- Iron Deficiency Anaemia
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Risk Factors for Adenocarcinoma of the Oesophagus:
- Acid Reflux
- Barrett's Oesophagus
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Presentation in Oesophageal Cancer
- Symptoms are ill defined in early disease
- Progressive Dysphagia
- Weight Loss
- Acute obstruction
- Pain
- Productive cough - aspiration / fistula
- Hoarseness - Recurrent Laryngeal nerve involvement
- Haematemasis
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Investigations in Oesophageal Ca.
- Barium swallow
- Endoscopy - biopsies can be take
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Staging Oesophageal Cancer
- T - Endoscopic Ultrasound scanning
- N - CT scan
- M - PET CT scan
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Treatment of Oesophageal Cancer (Surgical)
- Endoscopic submucosal resection*
- Radio-frequency ablation*
- Surgical resection - only if no spread, locally accessible and patient fit for GA.
- *high risk of local recurrence therefore follow-up scope advised.
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Treatment of Oesophageal Cancer (medical)
Chemotherapy with 5-fluorouracil and cystplatin can be used on local tumour
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Treatment of Oesophageal Cancer (Palliative)
- Endoscopic insertion of metal stend can improve dysphagia
- Beam radiotherapy
- possible role of chemotherapy in metastatic disease
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Prognosis in Oesophageal Cancer
- Prognosis is good in tumours confined to the mucosa.
- Prognosis falls steeply to 5% 5yr-survival in full thickness tumour.
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Causes and Contributing factors in Peptic Ulcer Disease
- H. Pylori - Gram -ve bacillus that produces alkaline environment. This increases acid production and a damaging immune response
- Drugs - NSAIDS and steroids disrupt prostoglandin synthesis in the gastric mucosa, leaving it open to damage from acidic environment.
- Stress Ulcers:
- Burns = Curlings
- Surgery = Cushings
- Hypersecretory States - Zollinger-Ellison syndrome caused by gastrinoma.
- Hypercalcaemia - Cirrhosis, CRF, COPD and hyperparathyroidism.
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Presentation of Gastric Ulcers
- Epigastric Pain, ? relieved by eating
- Weight loss
- N+V
- Iron deficiency anaemia
- Bleeding
- 10% proceed to malignancy
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Presentation of Duodenal Ulcers
- Epigastric Pain
- 10% painless
- Nocturnal Pain
- Relapsing/Remitting
- Bleeding
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Investigations
- OGD - Visualise ulcers and confirm diagnosis.
- - If gastric ulcer is found, at least 6 biopsies should be taken
- - Repeat post-therapy to check ulcer healing.
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Diagnosing H. Pylori
- Culture
- Serology
- CLO - takes 24 hours. false negatives on PPIs and requires OGD.
- Breath test - Carbon 14 tagged urea ingested. If Carbon 14 present in breath then it was broken down in stomach = H. Pylori present.
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Complications of Peptic Ulcers
- Bleeding - can be severe, causing shock
- Perforation
- Pyloric outlet obstruction
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Medical Treatment of Peptic Ulcers
- Acid Suppression - PPI or H2-antagonists
- H. Pylori erradication - PPI + two antibiotics
- Acid Neutralisation
- Barrier Drugs - Succralfate or Bisthmus Compounds
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Surgical Treatment of Peptic Ulcers (RARE)
- Resection of the ulcer and reconstruction with Bilroth I/II for example.
- In duodenal disease, vagotomy of varying degree is the surgery of choice.
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Presentation of Gastric Adenocarcinoma
- General Features - Anorexia, Weight Loss and Anaemia
- Local Signs and Symptoms:
- - Epigastric Pain
- - Vomiting
- - Dysphagia
- - Perforation / Haemorrhage
- - Mass
- Signs of Metastasis - e.g Jaundice, ascites and bone pain.
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Risk Factors for Gastric Adenocarcinoma
- Blood Group A
- H. Pylori infection
- Previous gastric surgery
- Family History
- Pre-malignant disease
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Pre-malignant Gastric conditions
- Polyps
- ulcers
- Chronic Gastritis
- Pernicious anaemia
- Hypertrophic Gastropathy - large gastric folds
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Investigations of Gastric Adenocarcinoma
- OGD
- Barium Meal - linitis plastica
- CT / PET CT for staging
- EUS to assess depth of invasion
- Diagnostic laparoscopy
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Surgical Treatment of Gastric Cancer
- Partial / subtotal gastrectomy - for distal tumours
- Total gastrectomy - for middle and upper tumours. Reconstruct with Roux-en-Y or oesophagojejunostomy
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Palliative Surgery in Gastric Carcinoma
- Bypass of obstruction
- Stenting
- Naso-jejunal feeding
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